Moving Beyond Diagnosis Codes in CDI: Documentation Improvement for CPT

Moving Beyond Diagnosis Codes in CDI: Documentation Improvement for CPT

This monthly blog will discuss all the components of quality clinical documentation with a comprehensive approach to cover all areas of the healthcare industry.



Clinical documentation specialists (CDSs), regardless of their work in an inpatient or outpatient setting, are primarily focused on documentation opportunities that reflect accurate, complete, and clinically valid diagnostic conditions able to be translated into the most specific ICD-10-CM codes. Correct diagnosis coding helps ensure facilities can report the most accurate DRG to capture resource utilization during an inpatient stay, metrics that reflect severity of illness (SOI) and risk of mortality (ROM), and factors for risk adjustment and HCC reporting. Focusing entirely on clinically supported diagnosis codes, however, can prevent CDSs from considering other documentation improvement opportunities, including services and procedures reported with codes from the Current Procedural Terminology (CPT) code book. CPT codes are used to report medical services and procedures performed by physicians and are designated by the US Department of Health and Human Services (HHS) as the national coding standard for physicians and other healthcare professional services under HIPAA.

Just as ICD-10-CM codes are used to translate clinical diagnoses into codified language, CPT codes identify diagnostic and therapeutic procedures and services using a systematic five-digit code. The format of the terminology and guidelines for interpretation and application of specific CPT codes are clearly stated within the context of the Current Procedural Terminology code book for the current year. CPT code assignment requires users to understand and apply the guidelines and coding rules specific to the nomenclature. Further guidance is issued by the AMA CPT® Assistant, a monthly publication issued by the American Medical Association (AMA) that provides additional specific code application instruction similar in format to the American Hospital Association’s Coding Clinic publication.

CPT codes are used to accurately identify the service performed and the assignment of a specific code requires adequate documentation that matches with the code definition. Documentation that is incomplete, vague, or lacking certain required components of the CPT code definition may result in medical services that are not reportable for reimbursement and quality measures.

So, what are a few examples of areas of opportunity for documentation improvement that involve CPT codes?

Injections and Infusions

Despite years of focused education specific to documentation requirements for injection and infusion services, coders still struggle to obtain documentation that is complete and explicit and that contains the necessary elements to assign a procedure code. Codes for injection and infusion services are defined by documentation that specifies:

  • Site (anatomic location) of injection or infusion
  • Route of administration (i.e., subcutaneous, intramuscular, intravenous, intradermal)
  • Substance administered (i.e., fluids, medications, diagnostic contrast, etc.)
  • Quantity of substance ordered and administered

Codes for infusion services are further defined by documentation to report:

  • Intent of infusion (hydration, therapeutic, chemotherapy)
  • Infusion time (i.e., start and stop time for the infusion or total infusion time)
  • Technique of administration (i.e., push or drip)
Excision of Skin Lesions

Correct procedure code assignment for diagnostic and therapeutic treatment of skin lesions requires procedure documentation that allows the CDS or coding professional to accurately identify the procedure performed. Axes of CPT codes for integumentary procedures include:

  • Paring or cutting
  • Removal of skin tags
  • Shaving of epidermal lesions
  • Excision of benign lesions
  • Excision of malignant lesions

Complete procedure description is necessary to assign an accurate code that reflects the service performed. Code assignment is primarily determined by the type of lesion being treated, the size of the lesion (including margins), and the closure or repair following the procedure. Simple closure following excision is included in the removal and is not separately reportable. Intermediate, layered, or other types of closure may be reported in addition to the excision procedure. Intermediate closure should include specific detail for the depth of the defect and specifically identify the deeper dermal layers included. Notation of “layered repair” is not sufficient to assign an intermediate repair code. Documentation for correct procedure code assignment for each lesion should contain the following:

  • Anatomic location of the lesion
  • Preoperative diagnosis (including reason for removal if indicated)
  • Postoperative diagnosis, if possible (Note: lesions with uncertain morphology may not have a definitive post-op diagnosis assigned until pathologic examination is completed)
  • Size of lesion including skin margins required for complete excision (lesion diameter plus the narrowest margin required equals the excised diameter)
  • Method or technique used for excision
  • Type of closure, including depth and specific dermal layer included in closure
  • Notation of any complications
Wound Debridement

Debridement procedures by physicians performed using a scalpel or other sharp instrumentation such as a dermatome to excise tissue until viable tissue is exposed. Wounds treated by debridement may be the result of injury, infection, chronic ulcer, or other causes. Burn wounds are not reported using general debridement codes and a specific category of CPT codes for burn debridement should be reported. Debridement codes are reported by documentation that specifies:

  • Anatomic location of wound
  • Depth of tissue removed
  • Surface area of the wound

When treating multiple wounds, clinicians must document the specific details for each area treated to enable accurate code assignment.

CPT coding presents unique challenges that may be new to CDSs, but the opportunities for provider query and education are just as important as those associated with diagnosis codes. Understanding the structure, format, and guidelines for procedure codes can be a rewarding expansion of documentation improvement efforts in any organization.


Clinical Documentation Improvement Desk Reference for ICD-10-CM and Procedure Coding 2018. Optum360, 2017.

CPT 2018 Professional Edition. Chicago, IL: American Medical Association, 2017.


Betty Stump is a Medicare consultant at Quality Field Operations.

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